Pacific Hills Post Acute

Based on interview and record review, the facility failed to update and revise comprehensive and individualized care plans for hospice care (a specialized support system, focusing on resident's comfort, quality of life and dignity than cure for residents with serious illnesses with prognosis of six months) after hospice care services was discontinued for one of three sample resident (Resident 57).This failure in care planning had the potential for not meeting Resident 57's needs.Findings:Review of Resident 57's face sheet (FS: a document that provides resident's information at quick glance) indicated Resident 57 was admitted to facility on 4/2/2025.Review of Resident 57's discontinued orders indicated Resident 57 was discontinued from hospice care services on 11/18/2025.Review of Resident 57's care plans indicated care plans for hospice services, self - care deficit, at risk for falls and injuries, mood problem, depression, potential for pressure ulcer development, impaired skin integrity, incontinent of bowel and bladder, actual/chronic pain related to hospice care, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of four residents (87 and 132) when:1. Resident 87's oxygen tubing was not changed weekly as ordered by the physician; and,2. Licensed vocational nurse C (LVN C) and licensed vocational nurse D (LVN D) did not know Resident 132 had a pacemaker (a small, battery-operated electronic device implanted in the body to regulate heartbeats), and Resident 132's pacemaker information was not in his medical records.These failures had the potential for adverse effects on the patients' health and well-being.Findings:1. Review of Resident 87's admission Record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, diseases that restrict the breathing) diagnosis.Review of Resident 87's physician orders, dated 11/18/25 and 10/23/25, indicated he had orders for oxygen at 2 liters (L, a metric unit of volume) per minute as needed and change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify fall risk to prevent falls for one of five residents (87) when Resident 87's fall risk was not assessed after he fell. This failure had the potential for Resident 87's fall risk score and interventions to be inaccurate.Findings:Review of Resident 87's admission Record indicated he was admitted to the facility on [DATE] with muscle weakness diagnosis.Review of Resident 87's Fall Report of Incident and Change of Condition Fall indicated he fell on [DATE] and 11/25/25. However, there were no indications that Resident 87 was assessed for fall risk after he fell.During an interview with the director of nursing (DON) on 12/5/25 at 1 p.m., she reviewed Resident 87's clinical record and confirmed that Resident 87 was not assessed for fall risk after he fell on [DATE] and 11/25/25. The DON stated the residents should be assessed for fall risk after the fall.Review of the facility's policy, Fall Risk Assessment, dated 3/2018, indicated . the nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility had a medication error rate of 12% when 3 medication errors occurred out of 25 opportunities during medication administrations for two out of 10 residents (27 and 72). This failure resulted in medications to not be given in accordance with the prescriber's orders.Findings:1. During a medication pass observation with licensed vocational nurse E (LVN E) on 12/1/25, at 12:54 p.m., LVN E stated per the physician order, Resident 27 was to receive 9 units of insulin aspart (used to control high blood sugar) before meals. LVN E drew 8 units of insulin aspart 100 units/ml, brought the syringe with 8 units of insulin aspart to Resident 27, and was about to administer this to the resident.During a concurrent observation on the syringe with insulin aspart and interview with LVN E, she confirmed that she drew 8 units of insulin aspart to give to Resident 27 and not 9 units.Review of Resident 27's physician order, dated 4/6/25, indicated Resident 27 was to receive 9 units of insulin aspart 100 units/ml before meals three times a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate food preferences for one of 4 sample resident (Resident 85). This failure had the potential for decreased meal intake, thus negatively affecting the health and well-being for the sampled resident.Findings:During an initial dining room observation for lunch meal on 12/1/2025 at 12:26 p.m., noted Resident 85 was received lunch meal with no cranberry juice.Review of Resident 85's face sheet (FS, document that gives resident's information at a quick [NAME]) indicated Resident 85 was admitted to facility on 12/31/2025.Review of Resident 85's lunch tray card dated 12/1/2025 indicated that, Cranberry JC (juice) mildly TH (thick, flows easily but slower than water) 1/2 C (cup).During an interview with certified nursing assistant J (CNA J) on 12/1/2025 at 12:36 p.m., CNA J confirmed Resident 85's lunch tray card indicated cranberry juice 1/2 cup; and that, Resident 85 did not receive this juice with the lunch meal. CNA J stated Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was prepared palatable (quality of taste) for one of eight sample resident (Resident 97) when food was overcooked and lacked flavor. This failure had the potential to affect meal intake and the nutritional value of the food served to Resident 97. Findings:During an interview with Resident 97 on 12/2/2025 at 11:40 a.m., Resident 97 stated vegetables always served mushy, overcooked, no flavor, and do not feel like eating vegetables with meals.Review of Resident 97's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 97 was admitted to facility on 10/18/2017.Review of Resident 97's order summary report indicated an order for heart healthy diet, regular texture, NAS (no added salt) dated 12/21/2022.Review of facility's lunch menu for 12/4/225 indicated, seasoned zucchini for vegetable item.During a lunch test tray and interview with facility's cook and registered dietician (RD) on 12/4/2025 at 1:12 pm., the regular texture zucchini tasted bland, and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure communication with the hospice facility for one of seven residents (Resident 7) who were admitted to hospice, when a plan of care from hospice was not located. This failure had the potential to negatively affect the proper care and coordination of care of residents admitted to Hospice.Findings: During a record review of Resident 7's hospice binder located at nurse station 2, it lacked a plan of care. During an interview with the DON on 12/04/2025 at 2:44 p.m., the DON stated she was not sure about the hospice care plans for Resident 7 and stated she will check about care plans being in Resident 7's record or hospice binder. During a review of the facility's agreement with the hospice facility titled, First Amendment to Agreement for Nursing Facility, Inpatient and Inpatient Respite Services, effective 9/20/2019, indicated, . 2.1.7 Plan of Care. Per Section 2.1 of Appendix C and Section 2.2 of Appendix D of the Agreement, [the Hospice company] shall establish, modify as appropriate, and provide Facility with a copy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to implement infection control practices when:1. Certified nursing assistant I (CNA I) did not remove gloves before walking out of Resident 45's room;2. Registered nurse G (RN G) picked up the water pitcher on her medication cart with her contaminated gloved hand;3. Licensed vocational nurse H (LVN H) did not cleanse her hands and change gloves before administering eye drop to Resident 93; and,4. LVN H administered oral medications to Resident 76 with a contaminated spoon.These failures had the potential to spread infection in the facility.Findings:1. During an observation on 12/1/25, at 10:55 a.m., CNA I was helping Resident 45 in his room. Then CNA I carried a bag with soiled diaper inside with her gloved hands, walked out of Resident 45's room and in the hallway to throw the bag in the hamper.During a concurrent interview with CNA I, she stated she was changing Resident 45's brief. CNA I stated she should remove her gloves in Resident 45's room before walking out in the hallway.Review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of three residents investigated, (Resident 1), when Resident 1 did not have a care plan for his broken tooth. This failure had the potential to result in the resident, not receiving the proper intervention and monitoring necessary to maintain his highest level of well-being. Findings: During the observation of Resident 1 on 8/12/25 at 3:00 p.m., Resident 1 was in his room, laying in bed. He's alert, oriented, calm, comfortable and verbally responsive. Resident 1 confirmed that he had a broken tooth, but it was already extracted. Review of Resident 1's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including encounter for palliative care (specialized medical approach that focuses on improving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to have a procedure in place to ensure a resident who displays, or who has a mental disorder, receives appropriate treatment and services to correct the assessed problem for one of two sampled residents (Resident 1). The facility did not implement the psychiatry recommendations timely for Resident 1 after their assessment and psych evaluation was completed due to the facility not having a procedure to follow up with the recommendations from outside referrals. This failure resulted in a delay of starting Resident 1's new treatment plan by three weeks. This failure had the potential to negatively affect Resident 1's behavior and the safety of other residents in the facility. Findings: During a review of Resident 1's Diagnosis Information, undated, document indicated, Resident 1 was diagnosed with Schizophrenia, Unspecified [a serious mental health condition that affects how people think, feel and behave]. During a review of Resident 1's Care Plan dated, 6/28/22 indicated, a Focus of Potential Behavior disturbance Related to DX…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report the results of its abuse investigations to the State Agency (California Department of Public Health-CDPH) within five working of the incident for two of three sampled Residents (Resident 1 and Resident 2). When: 1. The facility failed to report the results of the investigation of Resident 1's verbal abuse allegation to CDPH within five working days of the alleged incident. 2. The facility failed to report the results of the investigation of Resident 2's psychological abuse allegation to CDPH within five working days of the alleged incident. These failures resulted in CDPH being unaware of the outcome of Resident 1's verbal abuse allegation investigation and Resident 2's psychological abuse allegation investigation. This failure also had the potential for Resident 1 and Residents 2's abuse allegations to not be investigated thoroughly. Findings: 1. During a review of Resident 1's SOC 341 (Abuse allegation reporting form) dated 5/28/24, SOC 341 indicated, an abuse allegation was reported to facility on 5/27/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting for two of three sampled residents (Resident 1 and Resident 2) when: The facility failed to provide thorough summary of findings including information obtained in interviews for abuse investigations for Resident 1 and Resident 2, to the State Agency (CDPH-California Department of Public Health) upon request. This deficient practice resulted in CDPH being unaware if the abuse allegations by Resident 1 and Resident 2 were investigated thoroughly. Findings: During a review of Resident 1's SOC 341 (mandated abuse allegation reporting form) dated 5/28/24, SOC 341 indicated, an abuse allegation was reported to facility on 5/27/24 at approximately 3 p.m. SOC 341 indicated, a verbal abuse from a staff member against Resident 1 was alleged. During a review of Resident 1's Verification of Incident Investigation (also known as 5-day report) dated 6/4/24, document indicated, the facility determined Resident 1's abuse allegation was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment for 1 (Resident #13) of 3 residents reviewed for MDS discrepancies accurately reflected the resident was receiving an antiplatelet medication, instead of indicating the resident received an anticoagulant medication. Findings included: CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, Chapter 3: MDS Items, N0415: High Risk Drug Classes: Use and Indication, revealed, Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day-look-back period (or since admission/entry or reentry if less than 7 days. The RAI User's Manual further indicated, Coding Instructions *Code all high-risk medications according to their pharmacological classification, not how they are being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) received the necessary care and services when: 1a. The interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) did not develop a change in condition plan of care (POC) for Resident 1; 1b. There was no close monitoring of Resident 1 for signs and symptoms of hypoglycemia (low blood sugar level) and no documentation of hypoglycemia protocol in Resident 1's clinical record; and 1c. Licensed nurses did not follow Resident 1's physician order for post operative (post-op, aftercare assessment and treatment after a surgery) follow-up with the surgeon. These failures had the potential to affect resident's care, health, and well-being. Findings: 1a. Review of Resident 1's admission Record dated 12/26/2023, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a sudden loss of kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure to assess, notify to physician and Resident's responsible party (RP: person act on behalf of resident), and document pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on bilateral (both) buttocks for one of two sampled resident (Resident 1). This failure had the potential for delayed wound healing, adverse effects on the health and wellbeing of Resident 1. Findings: Review of Resident 1 face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 11/14/2023. Resident 1's admission diagnoses including diabetes type 2 (high sugar levels in blood), and dementia (loss of cognitive functioning, thinking, and reasoning those interfere with daily functioning). Resident 1's FS also indicated family member assigned as RP for Resident 1. Review of Resident 1's braden scale for predicting pressure sore risk assessment upon the admission to facility dated 11/14/2023 indicated score of 14 (score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide needed care or services based on professional standards of practice to one of three sampled residents (Resident 1) when: 1. Resident 1 did not receive a Magnetic Resonance Imaging (MRI-scanner that uses magnetic and radio waves to generate images of the organs in the body) and physician was not notified regarding refusal of Resident 1; and 2. There was no documented evidence the physician was notified regarding the refusal of the MRI for Resident 1. These failures had the potential to negatively affect Residents 1 ' s health, due to the potential of an undiagnosed injury. Findings: During an interview on 12/19/23, at 1:11 p.m., with Resident 1, she was unable to answer simple questions. During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS- tool used to screen and identify the cognitive condition of residents), dated 10/7/23, the BIMS indicated, a score of 11 (indicating moderate cognitive impairment: confusion or memory loss that is happening more often or is getting worse during the past 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make notification of resident's change in condition for one of three sampled residents (Resident 1) when: 1.There was no documented evidence the nurses were notified by physical therapist (PT) and occupational therapist of Resident 1's sudden unsteadiness and impairment in balance; and 2.There was no evidence licensed nurses notified the physician and Resident 1's responsible party regarding the high blood pressure (BP, the pressure of blood pushing against the wall of your arteries) readings. These failures had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: 1. Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted on [DATE] with diagnoses including orthostatic hypotension (also known as postural hypotension - a form of low blood pressure that happens when standing up from sitting or lying down), dizziness and giddiness, and type 2 diabetes mellitus with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accident-free environment for 10 of 18 residents reviewed for fall, when: 1. Resident 10 had no fall risk assessment and neuro-checks (evaluation of person's nervous system) completed after she fell on floor on 1/10/21 and 2/07/21 while she was turning on her bed. Also, staff did not develop a new fall prevention intervention to prevent fall recurrence. Resident 10 complained of headache, neck and back pain and was transferred to the hospital for evaluation. 2. For Resident 19, the facility did not complete neurochecks and fall risk assessments after each fall episodes. Also, Resident 19's fall care plan did not develop new interventions to prevent fall recurrence. Resident 19 fell on the floor from the wheelchair in her room on 5/6/21 while attempting to use the restroom. She stood up then lost her balance and slid to the floor which resulted in an abrasion on her midback. 3. For Resident 68, the facility did not complete fall risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure three of 18 sampled residents (Residents 40, 43, and 78) who required dialysis, received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and intake and output (I & O) monitoring, and coordination with dialysis centers done. These failures could increase the risk for complications, and potential miscommunication between the facility and dialysis center. Findings: 1. Review of Resident 40's facesheet included diagnoses which included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis). During a concurrent observation and interview on 7/6/21 at 3:35 p.m., Resident 40 was eating his meal, claimed he came back from dialysis that day and had dialysis every Tuesday, Thursday and Saturday. A pitcher filled with ice was on his tray table. Resident 40 stated he ate the ice without any restrictions. Resident 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: 1. Discontinued controlled medications for 11 discharged residents were not removed timely from one of two medication carts (Med Cart #1) to prevent medication errors and potential for loss and misuse; and 2. Random controlled medication use audit for four out of four residents (Residents 10, 25, 67, and 291) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. The failure had the potential for misuse or diversion of controlled medications. Findings: 1. During an inspection for the Medication Cart #1 with licensed vocational nurse F (LVN F) on [DATE] on at 10:55 a.m., a locked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility's consultant pharmacist (CP) failed to identify and make recommendations to the facility regarding irregularities related to the residents' drug regimen for four of 18 sampled residents (Residents 17, 73, 22 and 82). These failures resulted in inadequately monitored medications, which could lead to unsafe and ineffective medications for residents, and unnecessary medications for the residents, which had the potential to place them at risk for harm or adverse consequences. Findings: Review of Resident 17's clinical record indicated she had the diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 17's Order Summary Report indicated she had a physician's order, dated 6/15/21, for Fluoxetine (medication used to treat depression) 10 milligrams (mg, unit of dose measurement) one capsule by mouth one time a day for depression. There was no specific target behavior (behavior intended to be reduced or eliminated by administering the medication) indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure 5 of 18 sampled residents (Residents 7, 17, 22, 73 and 82) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 7 received a high dose Seroquel (an antipsychotic medication) for physical aggression without evidence of physical aggression; without adequate indication for use; without a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose); and the staff failed to report to the physician the resident had been oversleeping (possible side effect of her medications) during the day; 2. Resident 22 was on mirtazapine (an antidepressant medication) for poor appetite without evidence of poor meal intake for the past three months; the care plan indicated other target behaviors (crying, sad facial expressions, anxiety, kicking); 3. Resident 82 was on quetiapine fumarate (an antipsychotic medication) for psychotic disorder manifested by (m/b)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for three out of six residents (Residents 40, 54, and 65). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications. Findings: 1. During a medication pass observation on 7/6/21 at 8:22 a.m. with licensed vocational nurse (LVN) G, she was observed offering 5 medications to Resident 54. Resident 54 refused most of his medications except two medications, losartan (for high blood pressure) 50 milligrams (mg) and the albuterol inhaler (medication for shortness of breath). During the observation, LVN G gave the albuterol inhaler to the resident who inhaled two puffs simultaneously, one after another, without allowing time in between the puffs. LVN G did not instruct the resident to allow time between the puffs. Shortly after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Many opened multi-dose eye medications, inhalers, and insulin (medication to lower blood sugar level) vials were dated with an open and discard date, to make sure they were not used beyond the discard date; 2. Many expired medications were not available for resident use; and, 3. Disposed medications and sharp medical instruments/devices were not accessible to unauthorized persons such as staff, residents, visitors, or anyone passing by the storage area. The deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date, and risk for lost/stolen, misuse, or abuse of disposed medications and devices. Findings: 1. During a medication pass observation on 7/6/21 at 9:12 a.m. with licensed vocational nurse J (LVN J), he was observed giving 6 medications to Resident 34 including the dorzolamide-timolol (combination of eye medications for increased pressure in the eye) eye drop.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain standards of food service safety when: 1. One of four dietary staff were working in the kitchen with unrestrained hair and, 2. One of two ice machines had a drain pipe outlet located at approximately the sa.m.e height as the top rim of the floor sink into which the pipe drained. When staff prepare food with unrestrained hair, a potential exists for residents' food to become conta.m.inated with fallen, unrestrained hair. An ice machine drain pipe outlet located too close in proximity to a floor sink has the potential to become contaminated with sewage, if the floor sink were to flood with sewage from a clog or backflow in the sewage system. 1. During an observation with the dietary manager (DM) on 07/06/21 at 8:40 a.m., Dietary Aide A (DA A) was in the kitchen food preparation area with unrestrained hair. During a concurrent interview, the DM confirmed the observation of DA A in the kitchen food preparation area with unrestrained hair. She stated DA A should wear a hairnet on his head when preparing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. During an observation on 7/6/2021 at 1:44 p.m., Resident 289 had an oxygen concentrator (machine used to deliver oxygen to the resident) in his room. The nasal cannula (tubing attached to the oxygen concentrator) was not labeled with a date. During an observation and concurrent interview with Resident 289 on 7/6/2021 at 3:41 p.m., the nasal cannula was still not labeled with a date. Resident 289 stated the last time he used his oxygen was earlier that day. During an observation and concurrent interview with registered nurse E (RN E) on 7/8/2021 at 8:26 a.m., Resident 289 was lying in bed receiving oxygen by way of nasal cannula. The nasal cannula was still not labeled with a date. RN E confirmed this observation. During an interview with RN E on 7/8/2021 at 8:33 a.m., she confirmed that Resident 289's nasal cannula should have been labeled with a date. RN E explained the nasal cannula should be changed every week. Review of the facility's policy, Oxygen Administration Per Nasal Cannula, dated 1/1/2014,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to treat one of 18 residents (Resident 21) with respect and dignity when staff did not ask permission from the resident before performing any procedure. This failure had the potential to cause emotional distress to Resident 21. Findings: During an observation on 7/7/21 at 9:50 a.m., Resident 21 was sleeping in bed covered with a blanket when certified nursing assistant B (CNA B) removed the blanket to show the resident's right lower leg wound without asking her permission. The resident stated, ohh, it's cold and pulled back her blanket to cover herself. During a concurrent interview, CNA B stated she should have explained the procedure and asked Resident 21's permission before touching her. Review of the facility's August 2009 policy and procedure, Quality of Life, Dignity, indicated each resident shall be treated with dignity and respect at all times. Staff shall keep the resident informed and procedures shall be explained before they are performed and residents will be told in advance. Staff shall promote,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility administered a psychotropic medication (drug that affects brain activities associated with mental processes and behavior) to one of 18 sampled residents (Resident 73) without informed consent from the resident. This failure had the potential to compromise the resident's right to be informed of, and participate in, his treatment. Findings: Review of Resident 73's clinical record indicated he was self-responsible (was his own health care decision maker). Review of Resident 73's Facility Verification/Informed Consent for Psychotherapeutic Drugs, dated 4/21/21, indicated the facility had informed consent to administer Seroquel (medication used to treat psychotic disorders) 25 milligrams (mg, unit of dose measurement) by mouth as needed every six hours for 14 days (until 5/5/21). Review of Resident 73's 7/2021 medication administration record (MAR) indicated he received Seroquel 25 mg by mouth two times a day from 7/1/21 to 7/6/21. During an interview with Minimum Data Set nurse D (MDSN D) on 7/9/21 at 12:41 p.m., she reviewed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respond to residents' call lights in a timely manner for two of five sampled residents (Residents 32 and 38), when: 1. Resident 32's call light was not placed within reach, and 2. Resident 38 waited 15 minutes for help to get up in the wheelchair. This failure resulted in the delayed response to residents' needs and could potentially cause resident emotional distress. Findings: 1. During review of Resident 32's clinical record, Resident 32 was admitted on [DATE], with diagnoses included left elbow injury, depression and chronic obstructive pulmonary disease. Review of Resident 32's quarterly MDS dated [DATE], indicated Resident 32 was cognitively intact and required extensive assistance with two-person physical assist during transfers and bed mobility. During concurrent observation and interview, on 07/08/21 at 9:55 a.m., Resident 32 was yelling Help! help! help! I can't breathe . He was lying flat in bed and his call light was placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for three of 18 sampled residents (Residents 82, 84 and 83). Failure to accurately assess had the potential to result in unmet care needs for the residents. Findings: Review of Resident 82's Fall Report of Incident dated 4/24/21 indicated she had an unwitnessed fall with skin tear and discoloration of right bicep (a muscle on the front part of the upper arm), and complained of stomach pain that resulted from another unwitnessed fall on 4/26/21. During a review and concurrent interview on 7/8/21 at 10:05 a.m., minimum data set nurse D (MDSN D) reviewed Resident 82's MDS, Section J dated 6/14/21. She stated Resident 82's two fall incidents with minor injuries were not coded accurately in Section J1900 which should have indicated two instead of one. MDSN D also stated she would do the correction. Review of Resident 84's clinical record indicates she was discharged to home on 4/30/21. Her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to complete the pre-admission screening and resident review (PASARR) for one of 18 sampled residents (Resident 343). Findings: During a record review and concurrent interview on 7/8/21 at 10:42 a.m., minimum data set nurse D (MDSN D) reviewed Resident 343's face sheet that indicated admission to the facility on 7/6/21 and did not find any documented evidence that a PASARR was completed since Resident 343's admission. The MDSN D stated a PASARR should be completed upon the resident's admission to the facility. Review of the facility's August 2018 revised policy, Pre-admission Screening and Resident Review, indicated the objective of PASARR is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. During admission and readmission the facility participates in or completes the Level 1 screen for all potential admissions regardless of payor source, to determine if the individual meets the criterion for mental disorder (SMI,SMD),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident 72's facesheet included diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, fear, or anxiety strong enough to interfere with daily activities), adjustment disorder with depressed mood, major depressive disorder (a mental health disorder characterized by persistent loss of interest in activities causing significant impairment in daily life), psychotic disorder with delusions (a severe mental illness in which a person cannot tell what is real and what is imagined). During a record review and concurrent interview on 7/8/21 at 9:23 a.m., minimum data set nurse D (MDSN D) reviewed Resident 72's PASARR completed on 2/25/21 that indicated Section V (Mental Illness) item 27 with missing response, and item 29 with incorrect response. MDSN D stated if these two items were correctly coded it would require Level II PASARR evaluation. Review of the facility's August 2018 revised policy, Pre-admission Screening and Resident Review, indicated the objective of PASARR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a resident centered care plan for monitoring of a resident's surgical incision (also known as surgical wound, a cut through the skin made during surgery) and urostomy (surgical procedure that creates an opening in the belly to which urine passes), use of antibiotic (medication to treat infection) for one of 18 sampled residents (Resident 343). A baseline care plan is needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Findings: Review of Resident 343's facesheet indicated admission to the facility on 7/6/21. His admission assessment dated [DATE] indicated presence of surgical incision at the right abdomen and a urostomy. Review of Resident 343's physician's order dated 7/6/21 indicated Cefepime (antibiotic) 2 grams intravenously (IV, route of administration via vein) every 12 hours for cholecystitis(inflammation of the gall bladder) for 7 days. During an observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide the necessary care and services for gastrostomy tube (GT, a tube surgically placed into the stomach used for feeding and medication administration) for two of 18 sampled residents (Residents 337 and 83), when: 1. For Resident 337, the head of the bed was in an almost flat position, the disconnected GT tubing was not capped, the GT site dressing, asepto syringe used to flush the GT before and after medication administration, and GT administration tubing were not dated. 2. For Resident 83, staff did not label and date the GT formula bag and administration tubing. These failures posed the risk for complications related to the GT. Findings: 1. During a concurrent observation and interview on 7/6/21 at 12:58 p.m., licensed vocational nurse F (LVN F) confirmed Resident 337's GT feeding was off and the disconnected tubing was not capped. The GT site dressing was intact and not dated. The aseptic syringe was on top of the table not properly kept in a container or covered. The GT administration tubing set was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart to obtain intravenous access for medication administration) line care for one of two residents (Resident 343) were done per professional standards of practice when: 1. Registered nurses (RNs) did not follow the physician's orders of PICC line dressing changes, measure and document external catheter length and arm circumference on admission. 2. Registered nurse did not follow the correct procedure of PICC line dressing change and measurement of upper arm circumference during dressing change observation. 3. Registered nurse did not develop a person-centered, resident-specific PICC line care plan and included PICC line-related information such as insertion site/location, date of insertion, external length of catheter, number of lumens (openings), type of catheter,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to provide adequate pain management for one of 18 residents (Resident 337) when prior care coordination between Rehab staff and nursing was not done to make certain the need to premedicate the resident before rehabilitation treatment (assessment, evaluation and treatment) was initiated. This failure had contributed to Resident 337's pain and discomfort. Findings: A review of Resident 337's clinical record indicated he had a fall on 7/8/21 when found on the floor next to his bed that resulted to a skin tear on his left elbow and pain on his left hip. During an observation on 7/08/21 at 2:55 p.m., while the surveyor was standing between Resident 337's bed (19-C) and Resident 343's bed (19-B), Resident 337 screamed in pain when a physical therapist (PT) and occupational therapist (OT) were working with him. The resident reported 5/10 pain when asked by the staff. Both staff continued to perform range of motion (ROM) to both lower extremities and assessment despite the resident's complaint of pain. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. Review of Resident 22's physician orders dated 3/23/21 included Basaglar KwikPen solution, Pen Injector 100 units/ml. (milliliter, unit of measurement), (Insulin Glargine) 10 units subcutaneously (under the skin) one time a day for DM 2 (diabetis mellitus type 2- insulin dependent diabetis). During an interview and concurrent record review on 7/12/21 at 10:02 a.m., the minimum data set nurse D (MDSN D) reviewed Resident 22's clinical record and did not find a care plan developed regarding resident's risk for hypo/hyperglycemia related to insulin use. The MDSN D stated base line care plan was important especially for residents with DM and she would develop one. Based on interview and record review, the facility failed to ensure two of 18 sampled residents (Resident 22 and Resident 43) were free from unnecessary medications. For Resident 43, the nursing staff did not develop and implement the care plan and monitor for signs and symptoms of adverse effects related to the use of Eliquis (an anticoagulant or blood thinner - to treat and prevent blood clots and stroke). For Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 40) was free of a significant medication error when he received Humulin Regular (R) (short-acting insulin, medication to lower blood sugar level) nine (9) dosages past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During a medication pass observation for Resident 40 on [DATE] at 4:47 p.m. with licensed vocational nurse (LVN) I, she was observed withdrawing into a syringe 2 units of the medication from the Humulin R 100 units/1 milliliter (unit of measurement) vial. After drawing up the insulin, LVN I was about to put it back in the medication cart when the surveyor asked to see the Humulin R vial. A green sticker label on the vial indicated it was opened on [DATE], and to discard after [DATE] (or 30 days from opening). LVN I said it was still good to give even…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.